Podcast
Questions and Answers
In the United States, the first programs for training nurses were affiliated with:
In the United States, the first programs for training nurses were affiliated with:
Which of the following is/are an example(s) of a health restoration activity? (Select all that apply)
Which of the following is/are an example(s) of a health restoration activity? (Select all that apply)
Which of the following aspects of nursing is essential to defining it as both a profession and a discipline?
Which of the following aspects of nursing is essential to defining it as both a profession and a discipline?
The charge nurse on the medical surgical floor assigns vital signs to the nursing assistive personnel (NAP) and medication administration to the licensed vocational nurse (LVN). Which nursing model of care is this floor following?
The charge nurse on the medical surgical floor assigns vital signs to the nursing assistive personnel (NAP) and medication administration to the licensed vocational nurse (LVN). Which nursing model of care is this floor following?
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A patient who suffered a stroke has difficulty swallowing. Which healthcare team member should be consulted to assess the patient's risk for aspiration?
A patient who suffered a stroke has difficulty swallowing. Which healthcare team member should be consulted to assess the patient's risk for aspiration?
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Which of the following is/are an example(s) of theoretical knowledge as defined in this chapter? (Select all that apply)
Which of the following is/are an example(s) of theoretical knowledge as defined in this chapter? (Select all that apply)
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Critical thinking and the nursing process have which of the following in common? Both:
Critical thinking and the nursing process have which of the following in common? Both:
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In which step of the nursing process does the nurse analyze data and identify client problems?
In which step of the nursing process does the nurse analyze data and identify client problems?
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In which phase of the nursing process does the nurse decide whether her actions have successfully treated the client's health problem?
In which phase of the nursing process does the nurse decide whether her actions have successfully treated the client's health problem?
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What is the most basic reason that self-knowledge is important for nurses? Because it helps the nurse to:
What is the most basic reason that self-knowledge is important for nurses? Because it helps the nurse to:
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Arrange the steps of the nursing process in the sequence in which they generally occur.
Arrange the steps of the nursing process in the sequence in which they generally occur.
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How are critical thinking skills and critical thinking attitudes similar? Both are:
How are critical thinking skills and critical thinking attitudes similar? Both are:
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The nurse is preparing to admit a patient from the emergency department. This best illustrates:
The nurse is preparing to admit a patient from the emergency department. This best illustrates:
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Which organization's standards require that all patients be assessed specifically for pain?
Which organization's standards require that all patients be assessed specifically for pain?
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Which of the following is an example of data that should be validated?
Which of the following is an example of data that should be validated?
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Which of the following is an example of appropriate behavior when conducting a client interview?
Which of the following is an example of appropriate behavior when conducting a client interview?
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The nurse wishes to identify nursing diagnoses for a patient. She can best do this by using a data collection form organized according to (select all that apply):
The nurse wishes to identify nursing diagnoses for a patient. She can best do this by using a data collection form organized according to (select all that apply):
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The nurse is recording assessment data. Which errors did the nurse make? (Select all that apply)
The nurse is recording assessment data. Which errors did the nurse make? (Select all that apply)
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A patient is admitted with shortness of breath, so the nurse immediately listens to his breath sounds. Which type of assessment is the nurse performing?
A patient is admitted with shortness of breath, so the nurse immediately listens to his breath sounds. Which type of assessment is the nurse performing?
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The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, how should the nurse position the patient for this portion of the admission assessment?
The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, how should the nurse position the patient for this portion of the admission assessment?
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What should a child do when encountering a gun?
What should a child do when encountering a gun?
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What should a nurse do next for an agitated patient who cannot be reoriented?
What should a nurse do next for an agitated patient who cannot be reoriented?
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What should the nurse do first if a person is clutching his throat?
What should the nurse do first if a person is clutching his throat?
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What should parents do to promote child safety in the home?
What should parents do to promote child safety in the home?
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What is the leading cause of unintentional death in the U.S. population?
What is the leading cause of unintentional death in the U.S. population?
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Which change in hygiene practices may be necessary as the patient ages?
Which change in hygiene practices may be necessary as the patient ages?
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Which healthcare team member can bathe a female patient of Orthodox Jewish faith?
Which healthcare team member can bathe a female patient of Orthodox Jewish faith?
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What factor places a client at risk for impaired skin integrity?
What factor places a client at risk for impaired skin integrity?
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How should a nurse document a lesion caused by tissue compression?
How should a nurse document a lesion caused by tissue compression?
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How should nursing assistive personnel proceed with a bag bath for a patient?
How should nursing assistive personnel proceed with a bag bath for a patient?
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Which intervention should a nurse choose for a morbidly obese patient to counteract pressure from skin folds?
Which intervention should a nurse choose for a morbidly obese patient to counteract pressure from skin folds?
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Which is considered a primary defense against infection?
Which is considered a primary defense against infection?
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Which rule must be observed to follow contact precautions?
Which rule must be observed to follow contact precautions?
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Which client can be safely paired with a client in protective isolation?
Which client can be safely paired with a client in protective isolation?
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Which action demonstrates a break in sterile technique?
Which action demonstrates a break in sterile technique?
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A mother breastfeeding her child passes on which antibody?
A mother breastfeeding her child passes on which antibody?
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What is the rationale for hand washing?
What is the rationale for hand washing?
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Which incident requires the nurse to complete an occurrence report?
Which incident requires the nurse to complete an occurrence report?
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What best describes source-oriented charting?
What best describes source-oriented charting?
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Which abbreviation can the nurse use to document that a patient has no known allergies?
Which abbreviation can the nurse use to document that a patient has no known allergies?
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What best describes nursing assessment flow sheets?
What best describes nursing assessment flow sheets?
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What should a nurse do if she forgot to document a dressing change?
What should a nurse do if she forgot to document a dressing change?
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What is the rationale for using an electronic health record (EHR) system?
What is the rationale for using an electronic health record (EHR) system?
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Based on his injury, which type of pain is this patient most likely experiencing?
Based on his injury, which type of pain is this patient most likely experiencing?
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Which pain management task can the nurse safely delegate to nursing assistive personnel?
Which pain management task can the nurse safely delegate to nursing assistive personnel?
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Which factor in the patient's past medical history dictates that the nurse exercise caution when administering acetaminophen (Tylenol)?
Which factor in the patient's past medical history dictates that the nurse exercise caution when administering acetaminophen (Tylenol)?
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Which action should the nurse take before administering morphine 4.0 mg intravenously to a patient complaining of incisional pain?
Which action should the nurse take before administering morphine 4.0 mg intravenously to a patient complaining of incisional pain?
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Which action should the nurse take when preparing patient-controlled analgesia for a postoperative patient?
Which action should the nurse take when preparing patient-controlled analgesia for a postoperative patient?
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Which nonsteroidal anti-inflammatory drug might be administered to inhibit platelet aggregation in a patient at risk for thrombophlebitis?
Which nonsteroidal anti-inflammatory drug might be administered to inhibit platelet aggregation in a patient at risk for thrombophlebitis?
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Which complication is the patient most likely experiencing with nausea and loss of motor function after receiving epidural analgesia?
Which complication is the patient most likely experiencing with nausea and loss of motor function after receiving epidural analgesia?
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Which client's breath sounds require immediate medical attention?
Which client's breath sounds require immediate medical attention?
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Based on the assessment finding of a pulse volume of 1, what should the nurse also assess?
Based on the assessment finding of a pulse volume of 1, what should the nurse also assess?
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Which of the following clients has indications of orthostatic hypotension?
Which of the following clients has indications of orthostatic hypotension?
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Which method of taking a temperature would be most appropriate for a client who has experienced prolonged exposure to cold?
Which method of taking a temperature would be most appropriate for a client who has experienced prolonged exposure to cold?
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Which of the following clients would have the most difficulty maintaining thermoregulation?
Which of the following clients would have the most difficulty maintaining thermoregulation?
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Which of the following clients should have an apical pulse taken?
Which of the following clients should have an apical pulse taken?
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Which situation requires intrapersonal communication?
Which situation requires intrapersonal communication?
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What is the best environment to discuss the possibility of abusive events with a patient?
What is the best environment to discuss the possibility of abusive events with a patient?
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Which goal is most appropriate for the orientation phase of the nurse-patient relationship?
Which goal is most appropriate for the orientation phase of the nurse-patient relationship?
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Which type of group has been organized for people coping with the death of a loved one?
Which type of group has been organized for people coping with the death of a loved one?
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Which response by the nurse is best when a mother asks about her son involved in a motor vehicle accident?
Which response by the nurse is best when a mother asks about her son involved in a motor vehicle accident?
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What step should a child take first if he sees a gun at a friend's house?
What step should a child take first if he sees a gun at a friend's house?
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Study Notes
Pain Assessment and Management
- Deep somatic pain arises from injuries to ligaments, tendons, nerves, blood vessels, and bones.
- Asking about a patient's pain can be delegated to nursing assistive personnel during vital sign checks.
- Acetaminophen poses hepatotoxic risks in patients with liver diseases, such as hepatitis B.
- Assessing respiratory status is crucial before administering opioids like morphine due to the risk of respiratory depression.
- A second nurse should verify the setup of patient-controlled analgesia to prevent dosing errors.
Medication Administration Guidelines
- Codeine's peak effect occurs 60 minutes post oral administration, requiring reassessment of pain.
- Aspirin is the only NSAID listed that inhibits platelet aggregation, useful in patients at risk for thrombophlebitis.
- Epidural catheter migration can cause nausea, motor function loss, and low blood pressure post-anesthesia.
Vital Signs and Patient Assessment
- A drop in blood pressure exceeding 10 mm Hg upon standing indicates postural hypotension.
- Stridor indicates possible airway obstruction and requires immediate attention, unlike other sounds such as crackles or wheezes.
- Assessing blood pressure is vital when weak pedal pulses are observed to determine potential circulatory issues.
Nursing Communication and Patient Interaction
- Intrapersonal communication includes self-talk, essential for a nurse’s self-assessment and motivation.
- Sensitive discussions about abuse should occur in private, non-threatening environments to ensure patient comfort.
- Orientation phase of nurse-patient interaction involves introducing oneself and addressing immediate needs of comfort and safety.
Group Dynamics and Health Management
- Therapy groups provide support for emotional issues, such as grief, unlike task-oriented or community committees.
- The nurse’s response to family members in distress should provide accurate information to alleviate anxiety and suspense.
Patient Safety and Emergency Response
- Individuals with orthostatic hypotension or dizziness present fall risks and require careful monitoring.
- Instruct children to stop and assess the situation if they encounter a firearm, prioritizing safety first.
- When addressing agitation in patients, comfort measures should be considered before restraints, as agitation may stem from discomfort.
Emergency Protocols
- If someone is clutching their throat, immediately ask if they are choking to assess the situation before taking further action.### Child Safety in the Home
- Install window guards to prevent falls; never leave windows wide open.
- Attaching a pacifier with a ribbon poses asphyxiation risks for infants.
- Whole grapes can pose choking hazards for young children; snacks should be appropriate for age.
- Firearms should be stored unloaded and out of reach, ideally in a locked cabinet.
Leading Cause of Unintentional Death
- Motor vehicle accidents rank as the leading cause of unintentional death in the U.S.
- Other causes include poisoning, falls, and drowning.
Hygiene Practices in Aging
- Older adults may need to bathe every other day due to decreased activity of sebaceous glands, leading to dryer skin.
- Increased use of moisturizers is recommended; reduce soap use to prevent further skin drying.
- Maintaining regular dental hygiene remains essential regardless of age.
Cultural Sensitivity in Healthcare
- Patients of Orthodox Jewish faith should receive personal care only from same-sex healthcare providers due to religious beliefs.
Risk for Impaired Skin Integrity
- Dehydration increases the risk for impaired skin integrity by causing skin to dry and crack.
- Body weight and stature do not contribute to risk in a patient of normal height and weight.
Documentation of Skin Lesions
- Document lesions from tissue compression as pressure ulcers.
- Other types of lesions include abrasions and excoriation, each defined by their causative factors.
Bag Bath Procedure
- A bag bath involves using 8-10 washcloths to cleanse the patient’s body comprehensively.
- It is not performed in a chair or bathtub but is an effective method for bed-bound patients.
Care for Morbidly Obese Patients
- Keeping linens wrinkle-free helps alleviate pressure from skin folds, a crucial consideration in morbidly obese patients.
Primary Defenses Against Infection
- Intact skin serves as a primary defense against infection, while other responses like fever and inflammation are secondary defenses.
Contact Precautions
- Wear clean gowns and gloves when engaging with patients under contact precautions to prevent the spread of infection.
Safe Client Pairing in Protective Isolation
- Patients free from infection, such as those with unstable diabetes, can be safely paired with others in protective isolation.
Sterile Technique
- Avoid reaching over sterile fields, as this breaks sterile technique. Maintain distance from nonsterile areas.
Antibodies in Breast Milk
- Breastfeeding transfers the IgG antibody to the child, providing passive immunity during infancy.
Purpose of Hand Washing
- Hand washing primarily removes transient flora from the skin, preventing infections and cross-contamination.
Occurrence Reporting
- An occurrence report is necessary for lost patient items, while other incidents like medication timing or equipment issues may not require one.
Source-Oriented Charting
- This method separates health records by discipline, allowing clear organization of documentation.
Documenting Patient Allergies
- Use "NKA" (no known allergies) to denote absence of allergies in patient documentation.
Nursing Assessment Flow Sheets
- Flow sheets integrate assessments and nursing actions, allowing for efficient documentation by body systems.
Late Entry in Documentation
- If a procedure like a dressing change is omitted in documentation, a late entry should be made rather than altering previous notes.
Rationale for Electronic Health Records (EHR)
- EHR systems enhance interdisciplinary collaboration and improve procedural efficiency, supporting better patient care.
History of Nursing Training
- The first nursing programs in the U.S. were affiliated with religious orders, providing foundational training before the establishment of general hospitals.
Health Restoration Activities
- Administering antibiotics and assessing surgical incisions qualify as health restoration activities, aimed at returning patients to health.
Defining Nursing as a Profession
- Professional nursing practice is based on scientific research, establishing its credibility as a discipline and a profession.
Nursing Care Models
- Functional nursing model divides tasks according to staff roles; e.g., NAP handles vital signs while LVNs administer medications.
Assessing Aspiration Risks
- Healthcare team members, particularly speech therapists, should be consulted for assessing patients with swallowing difficulties to guard against aspiration.### Health Professionals
- Respiratory Therapist: Cares for patients with respiratory disorders.
- Occupational Therapist: Helps patients regain function and independence.
- Dentist: Diagnoses and treats dental disorders.
- Speech Therapist: Assists clients with swallowing and speech disturbances; assesses aspiration risks and recommends treatment plans.
Theoretical Knowledge in Nursing
- Example of theoretical knowledge includes facts such as "Antibiotics are ineffective in treating viral infections."
- Principles from established theories, like "In Maslow's framework, physical needs are most basic," also qualify as theoretical knowledge.
- Practical knowledge consists of instructions like measuring blood pressure and medication administration techniques.
Critical Thinking in Nursing
- Critical thinking and the nursing process are essential in nursing practice.
- The nursing process includes specific steps, while critical thinking is a more general skill applicable across disciplines.
Nursing Process Steps
- The nursing process involves Assessment, Diagnosis, Planning Outcomes, Planning Interventions, and Evaluation.
- Diagnosis Phase: Analyzes data and identifies client problems.
- Evaluation Phase: Determines the effectiveness of interventions.
Importance of Self-Knowledge for Nurses
- Self-knowledge helps nurses identify personal biases that could affect their thinking and actions, which is fundamental in delivering unbiased patient care.
Nursing Diagnoses
- Identify nursing diagnoses using frameworks like Maslow's hierarchy and Gordon's functional health patterns for comprehensive understanding of patient needs.
Assessment Techniques
- The preferred order for examination techniques generally follows: Inspection, Palpation, Percussion, Auscultation, except during abdominal assessments where auscultation precedes palpation.
- For rectal examinations, certain positions (like Sims’) should be avoided post-hip surgery to prevent complications.
Examination of Children
- Demonstrating equipment before use is crucial for preparing children for examination.
- Parents should be allowed to stay with younger children to reduce anxiety.
Patient Positioning for Assessment
- Weak patients unable to sit unaided should be positioned in Semi-Fowler's to facilitate examination.
- The nurse should choose positions that promote comfort and safety while aligning with the examination requirements.
Auscultation Techniques
- The diaphragm of the stethoscope is used to listen to high-pitched sounds, such as bowel sounds, while the bell is necessary for low-pitched sounds like murmurs and bruits.
Body Mass Index (BMI) Categories
- A BMI of less than 20 is considered underweight; normal ranges are from 20 to 25; 25 to 29.9 indicates overweight, and BMI over 30 signifies obesity.
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Description
This quiz focuses on the fundamentals of nursing, specifically assessing pain types related to patient injuries. It features multiple-choice questions designed to enhance understanding of pain management principles in nursing practice.
